1346233905 NPI number — AMBULATORY SURGERY CENTER AT INDIANA EYE CLINIC LLC

Table of content: (NPI 1346233905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346233905 NPI number — AMBULATORY SURGERY CENTER AT INDIANA EYE CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMBULATORY SURGERY CENTER AT INDIANA EYE CLINIC LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346233905
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 N EMERSON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENWOOD
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46143-8895
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-881-3937
Provider Business Mailing Address Fax Number:
317-887-4009

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
30 N EMERSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GREENWOOD
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46143-8895
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-881-3937
Provider Business Practice Location Address Fax Number:
317-887-4012
Provider Enumeration Date:
08/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HAUSZ
Authorized Official First Name:
ANDREA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
317-881-3937

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  05-005394-2 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000217839 . This is a "BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 490005398 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 100274240A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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